INTRO TO WAY NURSES THINK (history) - ANS-Nursing Process- 1950 labeled by
Lydia Hall
critical thinking is How Nurses: - ANS-think, identify patient problems, determine patient
OUTCOMES, and PRIORITIZE patient care
STEPS OF NURSING PROCESS - ANS-5 step process based on scientific process
ADPIE
1) - ANS-A- Assessment
2) - ANS-D- (nursing) Diagnosis
3) - ANS-P- Plan
, 4) - ANS-I- Implementation
5) - ANS-E-Evaluation
Critical Thinking and the Nursing Process - ANS-Critical thinking-power of the nursing
DIAGNOSIS and the nursing PROCESS
INTERVIEWING YOUR PATIENT TO OBTAIN A HEALTH HISTORY - ANS-
Sources of info for the Healthy History - ANS-
Primary Source - ANS-CLIENT-interview
Secondary Source - ANS-not conscious, too young, delusional, cognitive impairment
-other individuals (family)
-client records and CHARTS
** secondary source if primary source NOT possible
2 Primary components of health assessment: - ANS-HEALTH HISTORY --subjective
data (cannot use senses, what a patient is TELLING you)
PHYSICAL EXAM - objective data (you assess, can see/sense
health history = subjective
-database used to create a PLAN, prevent disease, resolve problems, and minimize
limitations
-If patient cant verbalize, use OBJECTIVE data to determine pain
COMPONENTS OF COMPREHENSIVE HEALTH HISTORY - ANS-Biographic
data--initial visit
REASON for seeking care (CC)
History of PRESENT illness
Present health status
PAST medical history
Family history
Personal and psychosocial history
Review of all body systems
** most of health history is SUBJECTIVE DATA
HISTORY OF PRESENT ILLNESS - ANS-Should include the following data:
O= onset
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